6 peripartum care of high riskpregnancy (1)

8/10/2019 6 Peripartum Care of High RiskPregnancy (1)

1/85

COMPLICATIONS WITH THE PASSAGE


2/85

CEPHALOPELVIC DISPROPORTION

- A narrowing, or contractions, of the birth canal, whichcan occur at the inlets, midpelvis, or outlet, causes adisproportion between the size of the fetal head andthe pelvic diameters, or cephalopelvic disproportion(CPD). CPD results in failure of labor to progress


3/85

PRIMARY PROBLEMS

Malpositioning can occur because the fetuss

head isnt engaged in the pelvis.

Malpositioning can lead to further

complications. For example, if membranes

rupture, the risk for cord prolapse increases

significantly.


4/85


5/85


6/85


7/85

Abnormal poritions of the fetus canal so cause

CPD.

Fetal anomalies such as hydrocephalus,

hydrops fetalis and tumors of the fetal head

can also result in CPD.


8/85


9/85

DETECTION

A previous vaginal birth without any problemis substantial proof that the birth canal isconsidered adequate.

Pelvic measurement should be taken andrecorded before week24.


10/85

MANAGEMENT

A trial labor may be allowed to continue of descent of thepresenting part and dilatationof the cervix are occurring.

The following nursing measures areimportant in trial labor:

Monitor fetal heart sounds anduterine contractions continuously.

Make sure that the womans urinarybladder is kept empty to allowthefetal head to use all space, makingdelivery possible.


11/85


12/85


13/85


14/85

CEPHALOPELVIC DISPROPORTION


15/85


16/85


17/85


18/85

PROBLEMS WITH POWERS

Hypotonic Uterus

- contraction is weak; dilatation and effacement doesnot progress.

-oxytocin stimulation will be beneficial.

-occur during the active phase of labor


19/85

Induction or Stimulation of Labor

Elective Induction:

1. Pharmacologic means:

- Vaginal insertion of Prostaglandin E2, cervix softens andeffaces

- 8-12hrs after prostaglandin E2, oxytocin infusion

2. Mechanical means:

- amniotomy

-laminaria insertion

-nipple stimulation


20/85

Augmentation of Labor:

-assisting client when labor process is notprogressing normally ( prolonged labor) by

pharmacologic or mechanical means


21/85

Nursing Care of Clients During Induction of Labor:

Assessment

-Obstetric history- Maternal status:

- Uterine contractions

-Status of cervix, membranes

-ultrasound findings- Level of anxiety

- Fetal status:

- Gestational age- (-) CPD

- fetal monitor results


22/85

Nursing Diagnoses:

1. Anxiety r/t uncertainty of labor and birth process

2. Risk for infection r/t ruptured membranes

3. Pain r/t use of oxytocics

4. Risk for trauma r/t possibility of sustainedcontractions from oxytocin or fetal cord prolapsefollowing amniotomy


23/85


24/85

- D/C pitocindrip if:

sustained uterine contractions occur

fetal accelerations

decelerations persist urinary flow decreases to 30 ml/hr

signs of abruptio placenta appear

5. Monitor effect of prostaglandin6. Assist with amniotomy

maintain asepsis

monitor FHR immediately after rupture

Note time, color, amount of AF


25/85


26/85

Hypertonic Uterus - contractions are painfully strong andfrequent but ineffective in producing effacement anddilatation.

-Reposition patient and administer analgesic.

-Tocolytic drugs (ritodrine) maybe effective.

-occur in the latent phase of labor.


27/85

Pelvic Dystocia - abnormalities in any of the 3planes of the pelvis, inlet contraction, midplaneand outlet contraction.

-Contraction is low

-Cervical dilatation and effacement does notprogress

-Fetus fails to descent in the pelvic planes.


28/85

ABNORMAL PROGRESS IN LABOR


29/85


30/85

Labor Curves


31/85


32/85

PATHOLOGIC RETRACTION RING

PROLONGED LABOR

PELVIC DYSTOCIA


33/85

PATHOLOGIC RETRACTION RING


34/85

CESAREAN DELIVERY


35/85

CS delivery Indications:

1.CPD2.malposition

3.Malpresentation

4previous CS

5.complete or partial placenta previa

6.abruptio placenta

7.prolapsed umbilical cord8.fetal distress


36/85

Obstetric Intervention

Types:

1. Low Segment

incision done on lower uterine segment

blood loss is minimal

possibility of later uterine rupture is lessened

2.Classic

incision is made on the wall of the body of the uterus

done for anterior placenta previa done for transverse lie


37/85


38/85

PFANNENSTIEL ( BIKINI) INCISION


39/85

PFANNENSTIEL


40/85

VERTICAL ABDOMINAL INCISION


41/85

Indications of Cesarean Section


42/85

Obstetric Interventions:

Nursing Care:a. monitor vital signs closely

b. check dressing site

c. inspect perineal padd. check uterine fundus for firmness

e. breathing exercises

f. out of bed 1stpost-op day

g. have the woman hold the baby ASAP


43/85

Other Complications:

A. PREMATURE LABOR & BIRTH ContributingFactors:

a. multiple gestation

b. Polyhydramnios

c. PROM

d. incompetent cervix

E .placenta previa / abruptio placenta

f. previous preterm laborg. infection

Management :


44/85

Management :

1. Prevention of Premature Delivery

- if woman is currently in preterm labor, she is admitted to the hospital

Bedrest monitoring of contractions

IE

Tocolytic drugs ( Ritodrine, Terbutaline SO4)

Patient Teaching:

- teach woman symptoms of preterm labor

uterine contractions irregular pattern for more than 1 hour while at rest

intermittent or constant uterine cramps

low, dull backache & abdominal cramping

rupture of membrane

f l h b h l


45/85

Nursing Care of Clients with Preterm Labor with TocolyticTherapy:

A. Assessment

1. Number of weeks of gestation2. Presence of live and viable fetus

3. Presence of labor:

2 contractions lasting 30 seconds in a 15 minute period

cervical dilatation less than 4 cms

effacement of 50% or less

4. No signs of hemorrhage or infection

5. Presence of severe PIH

6. Prolonged rupture of membranes7. Emotional impact on mother


46/85

Analysis/Nursing Diagnoses:

1. Anxiety r/t uncertainty of labor and birth process

2. Ineffective family coping r/t need for specialized care andcontinued hospitalization of the newborn

3. Fear r/t acute status of baby and potential for death

4. Knowledge deficit r/t cause and treatment for preterm labor

5. Altered parenting r/t the physical condition of the baby

6. Situational low self -esteem r/t failure to carry pregnancy to fullterm

7. Risk of trauma r/t use of medications


47/85

Interventions:

1. Monitor VS, FHR, contractions and progression of labor

2. Maintain bed rest

3. Inform client about the medication; obtain consent

4. Provide emotional support; reduce anxiety and prepare for possibleloss of baby

5. Provide special care related to the administration of tocolytic drugs

6. Prepare for use of glucocorticoid therapy for the fetus

7. Prepare for premature birth if labor continues

8. Provide home instructions for halting preterm labor


48/85

Evaluation/Outcome:

1. Labor ceases

2. FHT satisfactory

3. No adverse effects from tocolytic drugs

4. Anxiety decreases

5.Client and partner able to state recurring signs

of preterm labor


49/85

Other Complications:

PRECIPITATE DELIVERY - characterized by very strong contractions &delivery that occurs less than 3 hours of labor

Predisposing Factors:

multiparity

history of rapid labor premature or small fetus

large bony pelvis Risks:

perineal lacerations

hemorrhage

cerebral trauma


50/85

Management:

fetal monitoring- fht..

analgesia - nubain (nalbuphine); demerol

assess for birth injury

assess for cervical, vaginal & perineallacerations


51/85

Nursing Care of Clients During Precipitate Labor:

A. Assessment

1. Rapid cervical dilatation

2. Accelerated fetal descent

3. History of rapid labor

4. Frequent uterine contractions with decreased relaxation

B. Analysis/Nursing Diagnoses

1. Risk for maternal injury r/t rapid expulsion of fetus resultingin lacerations and hemorrhage

2. Risk for fetal trauma r/t cranial battering during rapid birth


52/85

Planning/Implementation:

1. Remain with mother and monitor closely

2. Keep emergency birth pack at bedside

3. Keep mother and partner informed throughout process oflabor and birth

Evaluation/Outcomes:

1. Mother is safe throughout labor and birth*babys are nose breathers

2.Neonate remains injury free during birth


53/85

UTERINE INVERSION

*baby out. Placenta next.. Delivered w/in 30mins.

Check for placental separation

*gushing of blood

*involution of uterus

*rising of fundus*lenghtening of the cord

*BRANTANDREWS MANUEVER-movement: up-down, right-left placenta


54/85


55/85

UTERINE INVERSION CORRECTION

UTERINE PROLAPSE/inversion


56/85

UTERINE PROLAPSE/inversion

- can happen to old women; multigravida.. ; who didnt give birth

& h-mole


57/85

UTERINE RUPTURE

*prolonged labor due to cephalopelvic

disproportion

*previous CS

*primigravida with prolonged cpd


58/85


59/85


60/85

PLACENTAL PROBLEMS

PLACENTA PREVIA

ABRUPTIO PLACENTA


61/85

Abnormally Adherent Placenta:

Accreta - attachment of the placental villi to themyometrium.

Increta - invasion of the placental villi into themyometrium.

Percreta -penetration of the placental villi through themyometrium to the serosa


62/85


63/85

PLACENTA ACCRETA


64/85


65/85

1.First Trimester

- ambivalence; focuses more on self

- fear

-possible decrease in sex drive

TASK:

Accepting the pregnancy, I am pregnant

2.Second Trimester

- increased awareness and interest in fetus

-acceptance of reality of pregnancy

- feeling of well-being

-preoccupation with self

TASK:Accepting the baby, A baby is growing inside

me

3. Third Trimester

f l b d d l


66/85

- anticipation of labor and delivery

- fears ( impending labor ) and fantasies

( motherhood) about pregnancy

- heightened introversion- view infant as reality vs fantasy

- spurt of energy during the last month

TASK:

Preparing for parenthood, I am a mother COUVADE SYNDROME - group of physiological & behavioral

manifestation experienced by the husban-

- are often the results of stress, anxiety & empathy for the pregnantwomen

Onset:3-5 days after birth


67/85

Onset:3 5 days after birth

Symptoms: sadness, fears

Incidence:75% of all births

Etiology :probable hormonal changes, life

changesTherapy :support, empathy

Nursing Role: offer compassion&understanding

*taking in centered on mothers feelings

*taking hold -return demo

*letting go: holding the baby


68/85

Onset: 1-6 months after birth

Symptoms: anxiety , feeling of loss,

sadness

Incidence: 10% of all births

Etiology : history of poor parental

relationship ,hormonal response

Therapy : counseling

Nursing Role: refer for counseling


69/85

Onset: within 1st month after birth

Symptoms: delusions, hallucinations

Incidence: 2% of all birth

Etiology : possible activation

of previous mental illness, hormonal

changes

Therapy : psychotherapy , drug

therapy

Nursing Role: refer for

counseling, safeguard mother

from injury to self or newborn


70/85

HIGH RISK POSTPARTAL CLIENTS:

BLEEDING

INFECTION

THROMBOEMBOLISM

PSYCHIATRIC DISORDERS

Postpartum Complications : Subinvolution

Description


71/85

Description

- Incomplete involution or failure of uterus to return to its norma lsize andcondition

Assessment : Pelvic pain or heaviness

Backache

Uterus is larger and softer than expected

Prolonged lochial discharge

Irregular or excessive uterine bleeding

Interventions:

Monitor fundal height and lochia

Prepare to administer methylergonovine maleate (Methergine) asprescribed


72/85

Postpartum


73/85

Postpartum

Complications:Hemorrhage

Description - Blood loss exceeding 500 ml. after vaginal childbirth or1000 ml. after cesarean birth

Assessment :

Early

Occurs during 24 hours after delivery Caused by uterine atony or laceration or inversion of uterus

Late

Occurs after the 24 hours following delivery

Caused by retained fragments of placenta


74/85

Signs of Uterine Atony :

Uterine fundus is difficult to locate

Soft or boggy fundus

Uterus becomes firm when massaged but loses tone when massage

is stopped Uterine fundus located above expected level

Excessive lochia, especially if it is bright red

Expulsion of excessive number of clots


75/85

Interventions:


76/85

Interventions:

Notify health-care provider if hemorrhage occurs

Assess client for uterine atony If uterus is not firmly contracted, massage fundus until it is firm

and to express clots that may have accumulated in the uterus (butdo not push on uterus)

Monitor client's vital signs and fundus every 5 to 15 minutes

Prepare to administer intravenous fluids, blood transfusions, andmedications such as oxytocin (Pitocin) to maintain firm contractionof uterus

If bleeding is due to a laceration, prepare client for repairof laceration


77/85


78/85

Postpartum Complications: Infection

Description - Any infection of the reproductive organsthat occurs within 28 days of delivery or abortion

Assessment :

Chills and fever

Anorexia

Pelvic discomfort or pain

Vaginal discharge Increased white blood cell count

Interventions:


79/85

Interventions:

Check client's vital signs and temperature every 2 to 4

hours Make mother as comfortable as possible; position her for

comfort and to promote vaginal drainage

Keep mother warmed if chilled

Isolate newborn from the mother only if mother isinfectious

Provide a high-calorie, high-protein diet and encouragefluids to 3000 to4000 ml/day if not contraindicated

Encourage frequent voiding and monitor client's intake and

output Monitor results of cultures if they were prescribed

Administer antibiotics according to organism, as prescribed

Postpartum


80/85

Postpartum

Complications:Endometritis

Description : Infection of uterine lining after delivery; caused by bacteria

that invade uterus at site of attachment of placenta

Infection may spread, involving entire endometrium andcausing peritonitis, paralytic ileus, or pelvic abscess

Assessment :

Chills and fever

Uterine tenderness and enlargement

Foul odor or purulent lochia; may increase or decrease involume

Malaise, fatigue, tachycardia


81/85

I nterventions:


82/85

Monitor client's vital signs

Obtain cultures of blood and lochia Assist client into Fowler's position to facilitate

drainage of lochia

Administer antibiotics and pain medication as

prescribed Instruct client in proper handwashing techniques

Initiate wound(contact) precautions as necessary

Breastfeeding may be restricted during infectiousperiod; if woman is breastfeeding, she may needto pump her breasts to establish and maintainlactation

Postpartum Complications:


83/85

Postpartum Complications:

Thrombophlebitis

Description: A condition in which a clot forms in a vessel wall as a

result of inflammation of the wall

Partial obstruction of vessel may occur

Increased levels of clotting factors in postpartumperiod place client at risk

Assessment :

Heat, tenderness, and pain in affected leg Swelling of affected leg

Homans' sign

Chills and fever


84/85

Swelling/Homans sign


85/85

- pain is felt when the foot is dorsiflexed on the affected area.

Do not massage

6 peripartum care of high riskpregnancy (1)

Documents